Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Avenue Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident reported rough handling by a CNA that resulted in left arm and shoulder pain, but the facility failed to document the incident or conduct a required assessment in the medical record. Nursing staff had inconsistent practices regarding documentation of such incidents, and the investigation did not include an interview with the resident or a physical assessment, despite facility policy requiring immediate examination and documentation.
Failure to perform hand hygiene and sanitize therapy equipment between residents during a group therapy session. A PTA was observed handling an ankle weight, gait belt, and front-wheeled walker between multiple residents without washing or sanitizing his hands or cleaning the equipment, and an LPN also touched a resident and her wheelchair without hand hygiene. The lounge lacked hand sanitizer or a handwashing station, and staff interviews and facility policy confirmed that hand hygiene and equipment disinfection were expected between resident contacts.
Uncovered catheter bag visible to others: A resident with intact cognition and an indwelling catheter was observed in bed with the drainage bag hanging at the side of the bed and yellow liquid visible from the room entrance. A CNA and an LPN both noted the bag was not covered and identified it as a dignity issue, while the IP and DON stated the catheter bag should be covered for privacy and dignity. The facility policy required the drainage bag to be covered with a privacy bag.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a history of aggressive and combative behavior, including delusions and physical aggression, struck another resident who was sitting in a hallway. Nursing documentation and a wound nurse assessment confirmed a bruise on the affected resident's thigh. Despite multiple clinical notes documenting the injury, the facility's investigation did not substantiate the incident as resulting in harm, and documentation did not reflect adequate follow-up or acknowledgment of the injury.
A resident with a history of traumatic brain injury, seizures, sepsis, and MSSA infection did not receive two scheduled doses of IV Cefazolin Sodium as ordered, and there was no documentation explaining the missed doses or provider notification. Nursing staff and leadership confirmed that required protocols for missed antibiotic doses, including documentation and provider contact, were not followed.
A resident with severe cognitive impairment and multiple health issues was found unresponsive outside in extreme heat due to inadequate supervision. The facility lacked a policy for monitoring residents outdoors, leading to the resident's critical condition and hospitalization. Interviews revealed inconsistencies in supervision practices and failure to enforce safety policies.
Failure to Document and Assess Following Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that the investigation and medical record documentation were complete and accurate for a resident following an alleged incident of abuse by a Certified Nursing Assistant. The resident, who was cognitively intact and had a history of generalized muscle weakness, joint derangements, and pain, reported that a CNA handled her left arm roughly during care, resulting in pain that required a muscle rub. Despite this allegation, there were no progress notes or clinical assessments documented in the resident's medical record regarding the incident or the reported pain in the left arm/shoulder after the alleged event. Interviews with nursing staff revealed inconsistent understanding and application of documentation policies. Some LPNs stated they would document incidents or complaints in the resident's chart, especially if there was a change in condition or physical issue, while others were unsure if this was required by policy. The Assistant Director of Nursing and the Director of Nursing indicated that allegations without physical injury were not documented in the medical record, and that investigations were conducted before any charting occurred. Review of the clinical record confirmed that no assessment or monitoring was documented for the resident's left arm/shoulder following the allegation, and the only update was to the care plan for psychosocial monitoring. Facility policy required that a licensed nurse immediately examine any resident upon receiving reports of alleged physical or sexual abuse, with findings recorded in the medical record. The policy also mandated immediate reporting, investigation, and support for the alleged victim. However, the investigation report did not include an interview with the resident, and there was no evidence that a physical assessment was completed or documented as required by policy. The lack of documentation and assessment following the allegation constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene and Sanitize Therapy Equipment Between Residents
Penalty
Summary
The facility failed to ensure infection control policies were followed during a group therapy session in the first-floor lounge involving Residents #44, #45, #55, #180, and #181. A Physical Therapy Assistant (PTA) led the session and was observed removing an ankle weight from one female resident in a wheelchair and placing it on a chair without sanitizing it, then placing the same ankle weight on Resident #44's leg without sanitizing his hands. The PTA also set up a front-wheeled walker for Resident #55, donned a gait belt around Resident #55's waist, and provided touching assistance during a standing therapy activity without washing or sanitizing his hands between residents. During the same observation, the PTA did not sanitize or wash his hands before touching Resident #181 or her wheelchair, unlocked the wheelchair, and pushed Resident #181 back to her room. The PTA then set up Resident #181 with personal items in reach and did not assist the resident with cleaning her hands. The PTA also did not wash his hands at the sink in the room or use the sanitizer dispenser located directly outside Resident #181's door before leaving the room and returning toward the lounge. The lounge did not have hand sanitizer, a handwashing station, or sanitizing agents such as spray or wipes available. The observation continued when the PTA returned to the lounge and picked up the same gait belt previously used, placed it on Resident #45 without sanitizing it, and placed the previously used front-wheeled walker in front of Resident #55 without sanitizing it. Interviews with therapy and nursing staff confirmed that hand hygiene was expected between residents and that therapy equipment such as gait belts, weights, and walkers should be sanitized between resident use. Facility policy stated that hand hygiene is required before and after direct contact with residents and that common-use equipment must be cleaned and disinfected before use on another resident.
Uncovered catheter bag visible to others
Penalty
Summary
The facility failed to ensure that an indwelling catheter bag was covered for Resident #176, who was readmitted with diagnoses including acute kidney failure, elevated white blood cell count, depression, and dysphagia. The resident’s MDS assessment showed a BIMS score of 14, indicating intact cognition, and the care plan included keeping the catheter bag and tubing below the level of the bladder and away from the entrance room door. However, there was no evidence of a cover on the catheter bag. During observations on August 19 and August 20, 2025, the resident was seen lying in bed with the catheter bag hanging on the side of the bed and yellow liquid visible from the room entrance. A CNA stated the bag was not covered and that this would be a dignity issue. An LPN also observed the uncovered bag and stated the resident had been readmitted from the hospital with an uncovered catheter bag, and that the facility does not use an uncovered plastic bag for privacy and dignity concerns. The IP stated the catheter bag should be covered for patient privacy and dignity, and the DON stated it should be placed in a covered bag and secured to the side of the bed or under the wheelchair. The facility policy on indwelling catheter care stated that the drainage bag should be covered with a privacy bag.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident with a history of dementia, altered mental status, and documented aggressive and combative behaviors, including hallucinations and delusions, approached another resident who was sitting at the end of a hallway. The aggressive resident called the other resident derogatory names and physically struck her multiple times. Nursing notes and staff interviews confirmed that the aggressor had a pattern of combative behavior, including previous threats and physical aggression toward staff and other residents. The resident who was struck had diagnoses of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, with mild cognitive impairment noted on assessment. After the incident, nursing documentation and a wound nurse assessment confirmed the presence of a bruise on the resident's thigh, which was attributed to the physical contact. Despite these clinical findings, the facility's investigation report concluded that the incident was unsubstantiated for injury, even though multiple nursing notes documented the bruise. Staff interviews revealed that the incident was reported and the residents were separated, with the aggressor being moved to another room and monitored. However, the facility's documentation did not reflect adequate follow-up or acknowledgment of the injury sustained by the resident who was struck. The facility's policy states that residents have the right to be free from abuse, but the actions and documentation in this case did not ensure that right was upheld.
Failure to Administer and Document Scheduled Antibiotic Doses as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with the resident's care plan by not administering scheduled doses of Cefazolin Sodium, an antibiotic, as ordered by the physician for a resident with a history of traumatic brain injury, seizures, sepsis, and MSSA infection. Specifically, the Medication Administration Record (MAR) showed that two scheduled doses were missed on separate dates, and there was no documentation in the resident's progress notes explaining the omissions or indicating that the physician was notified about the missed doses. The care plan required that medications be administered as ordered and that the resident be monitored for side effects, but these interventions were not followed. Interviews with nursing staff and facility leadership confirmed that the expected protocol for missed antibiotic doses includes notifying the provider, documenting the omission in both the MAR and progress notes, and extending the antibiotic course if necessary. However, in this case, there was no evidence that these steps were taken. The Director-in-Training also confirmed the missed doses and the lack of documentation, which did not meet facility expectations or policy requirements for implementing physician's orders and documenting care provided.
Inadequate Supervision Leads to Resident's Heatstroke
Penalty
Summary
The facility failed to provide adequate supervision to a resident, leading to a serious incident. The resident, who had severe cognitive impairment and multiple health issues including vascular dementia and COPD, was found unresponsive in a wheelchair outside in extreme heat. Despite the resident's cognitive and physical limitations, the facility did not have a policy for monitoring residents while outside, and the resident was left unsupervised in the courtyard during high temperatures. On the day of the incident, the resident was found with a dangerously high body temperature and altered mental status, indicative of heatstroke. The resident was discovered by an LPN during a smoke break, who then wheeled the resident inside for treatment. The resident's condition was critical, with vital signs showing severe hypotension and tachycardia. The facility's documentation revealed that the resident was dependent on assistance for mobility and transfers, yet was left outside unsupervised, leading to the incident. Interviews with staff and family members highlighted inconsistencies in supervision practices. The DON admitted there was no specific policy for monitoring residents outside, and the facility's policy on restricting access to the patio during extreme heat was not enforced. The lack of adequate supervision and failure to adhere to safety policies contributed to the resident's critical condition, resulting in hospitalization and subsequent hospice care.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Catalina Post Acute And Rehabilitation | 0.8 mi | ★★★★★ | 12 | 0 |
| Villa Maria Post Acute And Rehabilitation | 3.5 mi | ★★★★★ | 5 | 0 |
| Santa Rosa Care Center | 4.1 mi | ★★★★★ | 20 | 0 |
| The Center At Tucson | 4.2 mi | ★★★★★ | 0 | 0 |
| Haven Of Tucson | 4.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.